BriefInterventionsinSubstanceAbuse Therapies 59
TIP34Book
TrainerNotes
Module 2:
Brief Interventions
TIP34Reference
Chapter2:BriefInterventionsinSubstanceAbuseTreatment(pp.13-36)
TrainingEmphasis
1.KeyConceptsofBriefInterventions
2.ModelsUsedforBriefInterventions
3.ResearchonBriefInterventions
4. Types ofSettingsandClientsAppropriateforBriefInterventions
5.ApplicationsofBriefInterventionsinSubstance Abuse Treatment
6.DurationofBriefInterventions
7.EvaluationofEffectiveness ofBriefInterventions
8.StrategiesUsedforBriefInterventions
9.Participant StrategyIntegration
LearningObjectives
1.Participantswillbeabletoidentifythree keyconceptsaboutbrief interventions.
2.Participants will beabletoidentifythree models usedforbrief interventions.
3.Participantswillbeabletoidentifythree researchfindingsaboutbriefinterventions.
4.Participantswillbeabletoidentifythree settingsorclients appropriateforusingbriefinterventions.
5.Participantswillbeabletoidentifythree applicationsofbrief interventionswithsubstance abusers.
6.Participantswillidentifyonenewbriefintervention strategy to integrateintotheirpractice.
7.Participants willidentifyatleast onequalityassurance andimprovement procedureforthenewbriefintervention strategy.
BriefInterventionsinSubstanceAbuse Therapies 59
Agenda
1.Welcome(2Minutes)
2.Brief InterventionsSummaryGrid OverviewandDiscussion(20Minutes)
3.StrategyIdentificationExercise(10Minutes)
4.StrategyIntegration Mind-MapExercise(10Minutes)
5.AssignmentsandClosing(3Minutes)
Training Equipment and Supplies
1.Whiteboardanderasable markers–OR–newsprintpad,markers,andeasel
2.LCDprojector–OR–overhead transparencyprojector
3.PowerPointslideCD–OR–overheadtransparencies
4.Moveableseating
5.Nametags(optional, reusable or disposable)
6.Attendancerecord
7.Pens andcoloredpencilsorcrayons
8.Continuingeducation certificates(optional)
BriefInterventionsinSubstanceAbuse Treatment 59
ParticipantMaterials
DefinitionofTerms
Hazardous Drinking:Hazardousdrinkingreferstoalevelofalcohol consumptionorpatternofdrinkingthat, should it persist, is likely toresultinharmtothedrinker.
Harmful Drinking:Harmfuldrinkingisdefinedasalcohol use that hasalreadyresultedinadversementalorphysical effects.
DependentUse:Dependentusereferstodrinkingthat has resulted in negative physical, psychological, or social consequencesandhas beenidentified by major diagnostic tools.
ParticipantMaterials
(Oneforeachparticipant)
1.Module2Handouts
a.Module2Packet Cover
b.BriefInterventionsSummaryGrid
c. StrategyIdentificationExercise
d.StrategyIntegration Mind-MapExercise
2.Homework:HandoutsfornextTIP 34 Training Module
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Module2-Section1
BriefInterventionsinSubstanceAbuse Treatment 61
TimeClock
TrainerNotes
TimeClock
Welcome & Introduction
Time: 2 Minutes
Trainer Notes
Thissectioncanbedidacticorinvolvelowgroupinteraction.
Trainer andparticipantintroductionsare not necessary as these were doneinModule1.
TrainerScript
Welcome & Topic Introduction
WelcometotheTIP 34 Training ProgramonBriefInterventionsandBriefTherapies.
Our topicforthistrainingis“BriefInterventions.”
Brief interventions maybethoughtofasthebeginningelements on acontinuumofcare,andsomeformsofbriefintervention overlapintotherapy.
We willexploreavariety of aspects about briefinterventionsthatare highlightedontheBrief InterventionsSummary Gridinyourhandoutpacket.
We will also use the Strategy Identification Exercise and the Strategy Integration Mind-Map to identify a new brief intervention strategy that you want to integrate into your personal practice.
Module 2 - Section 2
Brief Interventions Summary Grid
Time: 20 Minutes
Trainer Notes
Thissectionisacombinationofdidactic presentationandlargegroup discussion. It caninvolvelowtohighgroupinteraction.
ThetrainershouldnotreadeachitemfromtheSummary Grid.Summarizingeach section ofthegrid, as well as addingadditionalinformationavailableinthetrainer scriptorthroughpersonalclinical experience, will make
BriefInterventionsinSubstanceAbuse Treatment 61
the trainingmoreinteresting.
Integrating group discussions with each section will enhance the effectiveness of the training. Group discussions allow participants to learn from one another as well as from the trainer.
The trainer always facilitates the group discussion and interaction. The trainer’s role is to provide expertise and guidance, and not to prescribe the use of any one model for brief interventions. The trainer maintains the focus of the discussions on the topic, and is also the leader and timekeeper for the group.
The focus topic of the discussions is the feasibility of using these approaches within the guidelines and services of the agency.
Thetrainercaninitiate discussion with open questions:
■Doesanyoneinthegrouphaveexpertise in usingbrief interventions?
■What typesofbriefinterventionsarewithintheestablished guidelines for our agency?
■Whattypes ofbriefinterventionsare currently used inouragency?
■Whatothertypes ofbriefinterventionscould be used in ouragency?
■Whatresources for brief interventions exist outside of ouragency?
TIP34 Reference
Chapter2:BriefInterventionsinSubstanceAbuseTreatment(pp. 13-36)
ParticipantWorkbook
■BriefInterventionsSummaryGrid
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Participant Workbook
Trainer Script
Key Concepts
Brief interventionscaninvolveavarietyofapproaches,rangingfrom unstructuredcounselingandfeedback toformalstructured therapy. Themaingoalsofbrief interventions areto:
1.Identifyifaclienthasasubstance abuse problem.
2.Raisetheclient’s awareness of the problem.
3.Reducetheriskofharmthat isassociated with thatproblem.
The key to a successfulbriefintervention istotargetasingle,measurablebehavioral change,andtoallowtheclient to experience successful change.
Thetypeofbriefinterventionstrategy used withaclientwilldependupontheindividual client characteristics andtheavailabilityof
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appropriateagencyservices.
Studieshaveshownthat certain clinicianskillsproducegoodbrief intervention outcomes such as gettingtheclienttoentertreatment, work harder in treatment, stay longer in treatment, and haveimproved outcomes after treatment(e.g.,higherparticipation inaftercareandbetter sobriety rates).Theseclinicianskillsinclude:
1.Anattitudeofunderstandingand acceptance toward the client
2.Activelistening
3.Helpingclients exploreandresolve ambivalence
4.Afocusonintermediategoals
5.AworkingknowledgeoftheStages-Of-ChangeModel
Avitalpartofthe intervention processismonitoringtheprogressofthe client or patientaftertheinitialintervention hasbeencompleted.
Brief Intervention Models
TIP 34 addressesfive different modelsthat are used for brief interventions. Thesebriefinterventionmodelsare:
1.Stages of Change
2. FRAMES
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3.Five Basic Steps
4.Reduction ofHarm
5.ActiveListening
Stages-of-Change
TheStages-of-ChangeModel,developed byDrs.ProchaskaandDiClementein1984,consists of five stages of change that represent theprocessofthinkingabout,beginning,andmaintaining behavior changes.
Understanding these stageshelpstheclinicianto:
1.Be patient
2. Accepttheclient’scurrentpositionregardinghis or her substance use
3. Avoid provoking client resistance
4. Mostimportantly,applythecorrectcounseling strategyforeach stageof readiness
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Byusingthismodel,thecliniciancan:
1.Assess the client’s stage of readiness
2.Planacorrespondingstrategy toassist himorherinprogressingtothenext stage
3.Implementthat strategy withoutsuccumbing to distraction
Oneofthemostprevalent clinicalchallengesencountered in brief
interventionsis ambivalence. Ambivalenceisthehallmark ofa person
intheContemplationStage of readiness.
The goal is to help the client become more aware of the ambivalence and the discomfort that accompanies it, and to inspire the client to progress to a stage of preparation or action.
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FRAMES
The FRAMESmodelincludes six elements thatarecriticaltoa briefinterventiontochangesubstanceabusebehavior. Developedby Drs. MillerandSanchez in1994,theacronym FRAMESwascoinedtosummarize these six active ingredients:
1.Feedback isgiventotheindividualaboutpersonal risk or impairment
2.Responsibilityforchange isplaced on the client
3.Advicetochange isgivenbytheprovider
4.MenuofOptions(alternative self-help or treatmentoptionsare offered to the client)
5.Empathicstyle is used incounseling
6.Self-efficacyoroptimisticempowerment is engendered intheclient
The FRAMEScomponentshavebeencombinedindifferent waysandtested in diverse settings and cultural contexts.
Five Basic Steps
Abriefintervention consists of five basic steps thatincorporateFRAMESandremainconsistent regardless of the number of sessionsorthelengthoftheintervention.
The Five Basic Steps are:
1.Introducing the Issue
2.Screening for Substance Abuse Problems
3.ProvidingFeedback
4.Talkingabout Change andSetting Goals
5.Summarizing andReaching Closure
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Providersdonothavetouseallfiveofthesecomponentsin everysession.The stepsthatareusedinanysessionshould reflectthe needsoftheclientandhisorherpersonal style.However,before eliminating stepsinthebriefintervention process,there shouldbeawell-defined reasonfordoingso.
The goals of each session are to:
1.Close the session on good terms
2. Arrange or schedule another session
3.End the sessionwiththeclientfeelingsuccessful
4. Instillconfidenceintheclientthat willenablehim or her to complete
plans or execute strategies that are developed in the session
Reduction of Harm
Brief interventions often address the very large group of mid-range substance users who have moderate and risky consumption patterns.
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Theseindividualsareresponsibleforadisproportionate share of substance-related morbidity, including loweredworkforce performance,motorvehicleaccidentsandotherinjuries,maritaldiscord,familydysfunction,andmedical illness.
The estimated 20 % of the adult population who use substance heavily or in inappropriate and high-risk ways are those most likely tocometothe attention of physicians, social workers,familytherapists, employers,teachers, lawyers, and police.
Brief interventions must sometimes focus onreducingharmorriskand moderating consumption patterns as a firstandsometimesonlygoal, dependingonthemotivation and needs of the client.
If substance abuseisplaced onacontinuumfromabstinence to severe abuse,anymovetowardmoderation andloweredriskcanbeseen as astep intherightdirection. Reducinghigh-riskbehaviorsisnotincongruouswithagoalofabstinence. Abstinenceistheultimate form of risk reduction.
Active Listening
Active listeningistheabilityto accurately restate the content, feeling,andmeaningoftheclient’s statements. Itisoneofthe most direct waystorapidlyformatherapeuticalliance withtheclient.
Active listening has also beencalled “reflective listening,” “reflecting,”
or“paraphrasing.”
Active listening involvesaskingopen-endedquestionstowhichtheclientmustrespond with a statement, rather than a simple yes or no.Open-ended questions areinvitations to shareandprovideameansto probe for
BriefInterventionsinSubstanceAbuse Treatment 63
important information. Theycommonlybeginwithwho,what,how,where,orwhen.
The three steps inactivelisteningare:
1.Listentowhatthe client says
2.Forma reflective statement
3.Testtheaccuracy ofyourreflective statementActivelistening saves time by:
1.Reducingorpreventing resistance
2.Focusingtheclient
3.Focusingtheclinician
4.Encouragingself-disclosure
5.Helpingtheclient remember what was said
Research
TIP 34 is based on research studiesfromthe1960stothe1990s.
Theweight of the evidence in research shows that brief interventionshave merit.
Brief Interventions in Substance Abuse Treatment 65
Brief, non-judgmental,motivational counseling is among the most effective of brief interventions.
Strongresearchevidence supports the use of brief interventionsforhazardous and harmful drinkers. Some research indicates that brief interventions have the potential to significantly reduce the harm, problems, and costs associated with moderate to heavy alcohol use by risky drinkers.
However,furtherresearchonbrief interventions isstill needed for
1.Women
2.Drugsotherthan alcohol
3.Clientswithco-occurring disorders
4.Specific levels of abuse and dependence for which brief interventions are less effective and more intensive treatment is required
5.Clientcharacteristics that favor the use of brief interventions
Types of Settings and Clients
Brief interventions can be used by a wide variety of healthcare, human resource, and other professionals in a wide variety of settings.
Brief Interventions in Substance Abuse Treatment 65
They can be used with clients before, during, and after substance abuse treatment.
It is now unrealistic and unnecessary for providers in settings outside of substance abuse treatment to avoid working with people with substance abuse problems or merely to refer them for specialty care.
A client or patient’s level of substance use can be detected through screening instruments, medical tests (e.g., urine testing), observation, or simply by asking about his or her consumption patterns.
Those clients who are considered to have risky or excessive patternsof substance abuse or related problems can receive a brief intervention. Brief intervention in opportunistic settings rarely require more than several sessions that can last from 5 - 60 minutes, and average 15 minutes in length.
Applications in Substance Abuse Treatment
Therearemanypotential benefits for using brief interventions in substance abuse treatment settings:
1. Reduceno-show rates for the start of treatment
2. Reducedropout rates after the first session of treatment
Brief Interventions in Substance Abuse Treatment 65
3. Increasetreatment engagement after intake assessment
4. Increasecompliance for doing homework
5. Increasegroupparticipation
6. Address noncompliance with treatment rules (e.g., smoking in undesignated places, unauthorized visits, or phonecalls)
7. Reduce aggression and violence (e.g., verbal hostility toward staff and other clients)
8. Reduce isolation fromother clients
9. Reduce no-showrates forcontinuing care
10.Increase mutual-help group attendance
11.Obtain a sponsor, if involved with a 12-Step program
12.Increase compliance with psychotropic medication therapies
13.Increase compliance with outpatient mental health referrals
14.Serve as interim intervention for clients on treatment program waiting lists
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Duration of Interventions
Brief interventions are generally shorter in length of time or number of sessions than other forms of treatment. They have been performed in time periods ranging from a few minutes up to six therapy sessions.
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TimeClock
TrainerNotes
Evaluation of Effectiveness
Effectiveness evaluations do not have to be time-consuming or complicated. They can be conducted in person, by phone, through the Internet, or by mail.
The effectiveness of brief interventions can be evaluated through:
1.Client participation
2. Treatment admissions
3.Discharge against medical advice rates
4.Client satisfaction surveys
5.Follow-up phone calls
6.Counselor-rating questions added to the clinical chart
Module 2 - Section 3
Strategy Identification Exercise
Time: 10 Minutes
Trainer Notes
■ Turnoffallnoisyaudio/visualequipmentduring small groupdiscussions.
■Beawareofanyexternalandinternaldistractionsfromthesmall groupdiscussions.
The trainer prepares participants for the strategy integration process. The purpose of this process is to encourage participants to develop new therapeutic skills for working with their clients.
The trainer invites participants to think about a particular client who would likely benefit from brief cognitive therapy.
The participants review the handoutfortheStrategy IdentificationExercise.This handout presents lists of strategies of the module topic, usually organized according to the basic conceptual models presented intheSummary Grid.
The trainer directs the participants to place a check (√) next to strategies s/he has used successfully in his/her practice, and to place a star (*) next to new strategies s/he wants to include in his/her clinical practice.
Brief Interventions in Substance Abuse Treatment 67
While the participants work on completing the Strategy Identification Exercise, the trainer is available to respond to questions and moves about the room to help participants.
The trainer facilitates a whole-group discussion about this exercise, asking participants to share which strategies they have successfully used with agency clients. Participants can later use staff members with successful experiences to help them integrate a new strategy into their own practice.
Participant Workbook
■BriefInterventionsStrategyIdentification Exercise
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Participant Workbook
GroupExercise
TimeClock
TrainerNotes
Trainer Script
Strategy Identification Exercise
The purpose of this training is to integrate new skills for brief therapy into our professional practice. You will begin this process by identifying one new strategy that you believe will be helpful for one of your current clients.
Please review theStrategy Identification Exercise for Brief Interventions
handout.This handout presents lists of brief intervention strategies that are organized according to the models presented in theSummary Grid.
The handout directs you to place a check (√) next to strategies that you have used successfully in your practice, and to place a star (*) next to new strategies that you would like to include in your clinical practice.
After completing this portion of the exercise, you select one new strategy (from the strategies with a star) to use with a current client.
This exercise gives us an opportunity to share successful experiences we have had with various brief intervention strategies.Please pay close attention to the expertise of our staff that is revealed in this exercise. You may want to recruit them to help you with yournew strategy.
Who would like to share your successful brief interventions experiences with us?
Module 2 - Section 4
Strategy Identification Mind-Map Exercise
Time: 10 Minutes
Trainer Notes
■Turnoffallnoisyaudio/visualequipmentduring small groupdiscussions.
■Beawareofanyexternalandinternaldistractionsfromthe smallgroupdiscussions.
Brief Interventions in Substance Abuse Treatment 67
Participants work individually to complete this exercise.
While the participants are working on theStrategy Integration Mind-Map,the trainer is available to respond to questions and moves about the room to help participants.
The use of colored pencils or crayons with this exercise helps to enhance an atmosphere of creativity for brainstorming. Brainstorming is for developing ideas, not for evaluating them. The trainer encourages participants to help one another with a non-judgmental attitude.
When most of the participants have completed the mind-map, the trainer may invite volunteers to share their strategy and plan with the rest of the group. Maintaining the group rule regarding respect is very important in this discussion so as not to discourage a participant from executing his/her plan.
Participant Workbook
■StrategyIntegrationMind-Map
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ParticipantWorkbook
GroupExercise
Trainer Script
Strategy Integration Mind-Map Exercise
You will develop a plan of action for utilizing your new strategy and evaluating its effectiveness. The Strategy Integration Mind-Map Exerciseis used for this purpose. This is in your handout packet.
The purpose of theStrategy Integration Mind-Mapisto develop a plan about how you will integrate the selected new brief intervention skill into your clinical practice.
You should select the ideas that are the best and most appropriate for your client. Do not put the name of your client on this form. However, you may want to include this strategy in your client’s treatment plan.
Mind-Mapping Directions
This exercise is a mind-map. Mind-mapping allows you to conceptualize the integration of a new strategy on one page, and in a manner that is more easily remembered than other forms of writing, such as outlines or lists.
It uses brainstorming to encourage the generation of new ideas, and allows you to organize your thinking by fitting ideas together into a conceptual “map.”
You can write or draw your ideas. You can have fun and be creative while you develop your ideas. The use of colors can help to separate different parts of your map. By personalizing the map with symbols and designs, you can develop a strategy that will be more easily remembered and used with your client.
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All ideas on the mind-map are related to the theme in the center. The ideas are connected to the central theme or to one another with lines or arrows to indicate their relationship. Key ideas for the strategy mind- map are suggested on the border of the exercise form.
Write your selected new strategy in the center of the mind-map, and then – using pens, colored pencils, or crayons – place related ideas in boxes, circles, lists, or drawings thatradiate from the center.
Would anyone volunteer to briefly share your strategy and mind-map with the rest of the group?
Module 2 - Section 5
70
Time Clock
TrainerNotes
ParticipantWorkbook
Assignments and Closing
Time: 3 Minutes
Trainer Notes
The trainer gives a brief preview of next training topic.
The trainer distributes the handout packet forthe next training session, and encourages the participants to read the Summary Grid and Strategy Identification Exercise before the training.
The trainer discusses date, time, and place of next training session.
The trainer gives TIP 34 reading references for the next training.
Participant Workbook
■ Handout PacketforNextTIP34 Training
Trainer Script
Reading and Homework
PleaseThank you for participating in this TIP 34 Training Program.
Our next training module will explore_____ [Training Topic].
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Please read theSummary GridandcompletetheStrategyIdentification
Exercisebefore the training.
The TIP 34 references for this training are______[relevant TIP 34 pages or chapter].
This training module is scheduled for [date, time, and place].
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Participant
Workbook
Module 2:
Brief Interventions
in Substance Abuse Treatment
72
Brief Interventions Summary Grid
Key Concepts
■The basic goal for a client—regardless of setting—is to reduce the risk of harm that may result from continued use of substances. The reduction of harm, in its broadest sense, pertains to the clients themselves, their families, and the community.
■Theprimary goals of brief interventions are to raise awareness of problems and then to recommend a specific change or activity (e.g., reduced consumption, accepting a referral, self-monitoring of substance abuse, attending a support group meeting).
■The key to a successful brief intervention is to extract a single, measurable behavioral change from the broad process of recovery that will allow the client to experience a small, incremental success. Clients who succeed at making small changes generally return for more successes.
■The specific goal for each client is determined by the consumption pattern, the consequences of use, and the setting in which the brief intervention is delivered.
■Recommend the ideal change to the client, but accept less if the client is resistant.
■Immediate successes are important to keep the client motivated.
■Offer changeoptions that match the client’s readiness for change.
■Empathic counseling is an important component of brief interventions, and is associated with larger reductions of use than more traditional confrontational therapy styles.